New Patient Form

Please complete and submit our online New Patient Package information located below prior to your first appointment. Simply input the information and click next, until prompted to submit. If the information is submitted properly, you will receive on-screen confirmation. Please answer all questions to the best of your ability. All of the information needs to be inputted at one time, so please take a few minutes to complete all of the pages.

If you are unable to complete this information online, please click on this link to download and print a hard copy to fill out and bring to your first appointment.

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Today's Date*

Date Format: MM slash DD slash YYYY

Patient Name*

PrefixFirstMiddleLast

Date of Birth*

Date Format: MM slash DD slash YYYY

Sex

Male

Female

Address

Street AddressCityState / Province / RegionZIP / Postal Code

Cell Phone

Home Phone

Work Phone

Email

Marital Status

Single

Married

SS#

Driver's License #/State

In accordance with the Federal Trade Commission’s Red Flag regulations to protect your medical record and identity.

Emergency Contact Person's Name

FirstLast

Emergency Contact Person's Phone

Referred By:

Referrer Address

Street AddressCityState / Province / RegionZIP / Postal Code

Reason for This Appointment*

Face Pain

Jaw Pain

Headaches

Fatigue/Breathing Concerns

Other

Other

Employer Name

Employer Phone

Employer Address

Street AddressCityState / Province / RegionZIP / Postal Code

Job Title

Payment Type

Insurance

Self-pay

Auto

Worker Comp.

Health Insurance Name

Health Insurance ID#

Member Services Phone Number

In accordance with the Federal Trade Commission’s Red Flag regulations to protect your medical record and identity.

Primary Insured Name

FirstLast

Primary Insured Date of Birth

Date Format: MM slash DD slash YYYY

Relationship to Primary Insured

Self

Spouse

Child

Other

Other

What are your three chief complaints for which you are seeking treatment?

Please select the 3 main complaints then rate your complaints for intensity on a scale of 0-10 with 0 being none and 10 being the worst.

Complaint #1

Complaint #1 Rating (1-10)

Complaint #2

Complaint #2 Rating (1-10)

Complaint #3

Complaint #3 Rating (1-10)

Medical History

Tell us your medical story.

When did your condition first occur?

What do you believe is the cause of your pain or condition? (Pick One)

Auto Accident

Fight

Injury

Motorcycle Accident

Fall

Work Related Accident

Accident

Athletic Endeavor

Illness

Weight

Job

Other

Other

Is there anything that makes your pain or discomfort worse?

Is there anything that makes your pain and discomfort better?

What other information is important to your pain or condition?

Allergic Reactions

Please list all medications and check or list the substances that have caused and ALLERGIC REACTION?

Current Medications

Please list all medications you are taking and the reason you take them. Include all over-the-counter medications, vitamins, herbs, etc.

Medication

Dosage

Reason

Previous treatments/medications for the condition we are evaluating.

Treatment and/or Medication

Doctor/Provider Name

Approximate Date of Treatment

Health and Medical History

Have you ever had prior orthodontic treatments?

Yes

No

Are you currently pregnant?

Yes

No

Are you currently breastfeeding?

Yes

No

Surgical History

Have you had your wisdom teeth removed?

Yes

No

Have you ever had a root canal or any other tooth removal for this condition?

Yes

No

Have you ever had Jaw Joint Surgery?

Yes

No

Have you ever had Orthognathic Surgery?

Yes

No

Any other types of surgery?

Medical History

Please check all that apply and leave all others blank, if there is anything not listed please indicate the information in the OTHER section.

Allergy Skin Testing

Allergen Desensitization

Hay Fever

Adenoidectomy

Tonsillectomy

Turbinectomy

Cancer

Chemotherapy

Radiation Therapy

Prostate Disorders

Renal Failure

Stress Incontinence

Urinary, Bladder Infections

Kidney Stones

Urinary Calculus

Osteoarthritis

Arthritis

Rheumatoid Arthritis

Osteoporosis

Fibromyalgia

Anemia

Bleeding/Clotting

Leukemia

HIV

Cataract

Visual Impairment

Glaucoma

Asthma

COPD

Bronchitis

Measles

Chicken Po

Smallpox

Diphtheria

Congestive Heart Failure

Heart Attack

Rhythm Disorder

Functional Murmur

Mitral Valve Prolaspe

Angina Pectoris

Prior MI

Coronary Artery Disease

Peripheral Vascular

Hypertension

Hepatitis

Acute Colitis

Irritable Bowel Syndrom

Esophageal Reflux

Esophageal Ulcer

Peptic Ulcer

Chronic Reflux Esphagitis

Esophagitis

Esophageal Stricture

Hiatal Hernia

Epilepsy

TIA

Stroke Syndrome

Multiple Sclerosis

Vascular Headaches

Depression

Bipolar Disorder

ADHD

Migraine Headaches

Facial Injury

Head Injury

Neck Injury

Mouth Injury

Diabetes Mellitus

Thyroid Disorders

Chronic Fatigue

Other History Items Not Listed

Current Symptoms

Please check all that apply and leave all others blank, if there is anything not listed please indicate the information in the OTHER section.

Feeling tired or poorly

Weight change

Chills

Fever

Headache

Facial pain

Sinus pain

Tooth pain

Neck pain

Neck stiffness

Lump or swelling in neck

Mouth sores

Difficulty swallowing (dysphagia)

Difficulty chewing

Dentures currently being worn

Dentures improperly fitting

Dizziness

Vertigo

Fainting (syncope)

Motor disturbances

Sensory disturbances

Decreased concentrating ability

Chest pain or discomfort

Palpitations

Slow heart rate

Leg pain with exercise

Cold hands/feet Cataract

Visual Impairment

Glaucoma

Asthma

COPD

Bronchitis

Measles

Chicken Po

Smallpox

Diphtheria

Joint pain, localized in the jaw (joint)

Diffuse joint pains (arthralgias)

Joint pain, localized

Joint swelling, localized

Muscle aches

Muscle cramps

Legs feel restless

Appetite

Heartburn

Nausea

Vomiting

Abdominal pain

Regurgitation

Yellow skin/eyes (jaundice)

Inability to pass gas

Bowel movement frequency

Diarrhea

Unable to control passing gas

Constipation

Rectal Pain

Temperature intolerance

Excessive sweating

Hot flashes

Muscle weakness

Muscle weakness

Sexual complaints

Changes in body proportion

Hair symptoms

Mood

Energy level

Behavior

Sleep disturbances

Neurological symptoms

Pruritus

Skin Lesions

Rashes

Other Symptoms Not Listed

Head Pain

If you have different levels of headaches, the below refers to the worst headache as opposed to a daily tension-type headache. Location L=Left R=Right B=Both

Frontal (Forehead)

L

R

B

Recent

Chronic

Severity

Mild

Moderate

Severe

Duration

Mins.

Hrs.

Day

Frequency

Occasional

Frequent

Constant

Parietal (Top of Head)

L

R

B

Recent

Chronic

Severity

Mild

Moderate

Severe

Duration

Mins.

Hrs.

Day

Frequency

Occasional

Frequent

Constant

Occipital (Back of Head)

L

R

B

Recent

Chronic

Severity

Mild

Moderate

Severe

Duration

Mins.

Hrs.

Day

Frequency

Occasional

Frequent

Constant

Temporal (Temple Area)

L

R

B

Recent

Chronic

Severity

Mild

Moderate

Severe

Duration

Mins.

Hrs.

Day

Frequency

Occasional

Frequent

Constant

Jaw Pain

L=Left and R=Right

Jaw Pain When Opening

L

R

Jaw Pain When Chewing

L

R

Jaw Pain at Rest

L

R

Jaw Sounds When Opening

L

R

Jaw Sounds When Chewing

L

R

Jaw Sounds at Rest

L

R

Jaw Locks Closed

Yes

No

Jaw Locks Open

Yes

No

Teeth Clenching

Yes

No

Day

Night

Teeth Grinding

Yes

No

Day

Night

Eye Related Conditions

Blurred Vision

Yes

No

Double Vision

Yes

No

Eye Pain

Yes

No

Pain or Pressure Behind the Eyes

Yes

No

Extreme Sensitivity to Light

Yes

No

Wear Glasses or Contacts

Yes

No

Ear Related Conditions

L=Left and R=Right

Buzzing in the Ears

L

R

Ear Congestion

L

R

Ear Pain

L

R

Hearing Loss

L

R

Itching or Stuffiness in the Ears

L

R

Pain Behind the Ear

L

R

Pain in Front of the Ear

L

R

Recurrent Ear Infections

L

R

Ringing in the Ear (Tinnitus)

L

R

Mouth & Nose Related Conditions

Dry Mouth

Yes

No

Chronic Sinusitis

Yes

No

Frequent Snoring

Yes

No

Burning Tongue

Yes

No

Broken Teeth

Yes

No

Frequent Biting of the Cheek

Yes

No

Sleeping Conditions

Sleep Positions

Side

Back

Stomach

Varies

Is it easy to fall asleep?

Yes

No

Do you feel rested upon AM waking?

Yes

No

Stopped breathing during sleep?

Yes

No

Average hours of sleep per night?

Do you wake often during the night?

Yes

No

Gasping or choking during sleep?

Yes

No

Do you use sleep aids?

Yes

No

If yes, what kind of sleep aids?

How much caffeine do you use daily?

Do you nap?

Yes

No

What is your bedtime?

What time do you get up?

Do you have shift work?

Yes

No

Do you sleep walk?

Yes

No

Do you have vivid dreams?

Yes

No

Have you ever had a Sleep Study (PSG)?

Yes

No

Result was:

Family & Social History

Family History

Diabetes Mellitus

Cancer

Loss of Hearing

Allergies

Stroke

Hypertension

Asthma

Heart Disease

CAD – Coronary artery disease

CHF – congestive heart failure

Pulmonary Hypertension

PVD – peripheral vascular disease

Migraine Headache

Cluster Headache

Meniere’s Disease

Neurofibromatosis Type1 (Recklinghausen’s Disease)

TMJ Problems

Social History

Life circumstance event

Caffeine use

Tobacco use

Smoking cigarettes

Alcohol

Drug use

Marijuana use

Occupation

Name*

By signing below, I authorize the release of all examination findings and diagnosis, report and treatment plans, etc. to any referring or treating health care provider. I additionally authorize the release of any medical information to insurance companies, or for legal documentation to process claims. I understand that I am responsible for all chargers incurred for my treatment regardless of insurance coverage.

FirstLast

Date*

Date Format: MM slash DD slash YYYY

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations?

Sitting and reading

Watching TV

Sitting inactive in a public place (ex. a theater or a meeting)

As a passenger in a car For an hour without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in traffic

Please add the total score from this assessment and provide it here.

Patient Signature Acknowledgement*

FirstLast

Date*

Date Format: MM slash DD slash YYYY

Health Care Practitioners and Patient Communication

Please provide us with the names and addresses of all of your doctors and health care providers.

Family/Primary Care Physician

Name

FirstLast

Address

Street AddressCityState / Province / RegionZIP / Postal Code

Family Dentist

Name

FirstLast

Address

Street AddressCityState / Province / RegionZIP / Postal Code

Please add other if relevant.

Orthodontist

Oral Surgeon

Endodontist

Name

PrefixFirstLast

Address

Street AddressCityState / Province / RegionZIP / Postal Code

Specialty Providers

Do you have a specialty provider you want to add?

Yes

No

Specialty

Name

PrefixFirstLast

Address

Street AddressCityState / Province / RegionZIP / Postal Code

Do you have a second specialty provider you want to add?

Yes

No

Specialty

Name

PrefixFirstLast

Address

Street AddressCityState / Province / RegionZIP / Postal Code

Do you have a third specialty provider you want to add?

Yes

No

Specialty

Name

PrefixFirstLast

Address

Street AddressCityState / Province / RegionZIP / Postal Code

Patient Signature Acknowledgement

By signing here, I am giving my permission to communicate with the above named health care providers regarding my treatment.

Patient Signature Acknowledgement*

FirstLast

Date*

Date Format: MM slash DD slash YYYY

Consent Form for Care

I agree to be evaluated and treated at AZTMJ, PLLC, (herein after referred to as The Practice) by Dr. Stan Farrell as deemed medically appropriate. I acknowledge that no procedure will be performed without having been provided appropriate information regarding treatment and possible side effects or consequences. Signing this document implies informed consent on the part of the patient. In this arena, the Practice is released from harm. Although the physician and staff will make efforts to obtain my appropriate medical history and information, the Practice shall not be held responsible for issues of omission or negligence on the part of the patient.
I further acknowledge that the Practice is not functioning as my primary care/family physician, and if there are issues dealing with my primary care or internal medicine, they may be referred to my primary care physician by the Practice. There may also be instances where the Physician of the Practice will refer me to additional specialty care and evaluation as needed.
As for my responsibility to the Practice, I agree to attend appointments and therapies as scheduled. Multiple missed appointments, or inappropriate behavior may result in termination of services and referral to their physicians. Failure to cancel or no show for appointments will be subject to a charge for that visit.
During your therapy, it may become necessary to discuss surgical treatment options if painful or restrictive joint function continues. This may include arthroscopic or open TMJ surgery and/or possible jaw repositioning surgery. Dr. Farrell will, if necessary, discuss these options thoroughly. Following initial appliance therapy, there may be decisions to make by the patient and doctor concerning stabilizing or correcting the bite at the natural jaw position, determined by your muscles, if necessary. As joints and muscles relax and heal, there will be changes in your bite (how your teeth come together). Once, it is felt that you have reached your optimum level of improvement, adjusting your bite to your new jaw position may be recommended.
As part of your care, you may receive injections of one kind or another. Usually, these are trigger point injections into the motor point of various painful muscles. On occasion, a joint injection or Synvisc/Hyalgan injection will be done. This consent for treatment acknowledges that there can be side effects from any injection. Side effects can include: allergic reactions, localized pain at the injection site or pain along the referral pattern of the nerve or muscle injected. On rare occasions more serious adverse events have been known to occur: fever, infection, muscle and bone atrophy, rash anaphylaxis, pneumothorax, breathing difficulty, sudden changes in blood pressure, convulsions, death.
If a procedure is going to be done, a further discussion will ensue, but you are encouraged to ask questions. We wish to empower you to seek a higher level of health by getting involved. Help us to understand you.
Headace TMJ Disorders,sleep Apnea are chronic conditions that are managed,not cured we are not able to guarantee that all patient's condition will improve Upon rare occasion,condition and symptoms may worsen
No Intra-Oral Exam Performed We will not be examining your teeth or oral cavity, even though we will be looking in your mouth for other issues. Additionally, we will not be taking x-rays of your teeth. It is your responsibility to have a general dentist examine and maintain you oral health. If you do not have a general dentist we would be happy to recommend one.
Imaging (CT MRI) It may be required to have imaging of the head and neck performed for diagnostic and treatment purposes. Ultrasound and ICAT units are available on premises or a referral to an imaging center will be made.
Stark Policy/Notice Dr. Farrell may at times refer patients to Lab Express for lab work or to AZPMR for evaluation & treatment: both facilities are owned and operated by family members. Dr. Farrell does not have ownership, any financial interests nor does he receive any monetary compensation from either of the above entities.
Drug and Urine Screening At random times at the doctor's discretion our patients may be asked to provide a specimen for screening. This is intended to understand what chemical factors are contributing to your symptoms. An inquiry to the State Pharmacy Board may also be performed when indicated.

Patient Signature Acknowledgement*

FirstLast

Date*

Date Format: MM slash DD slash YYYY

Financial Policy

Please be informed that your Insurance Company does not pay for everything and we cannot guarantee what services or items will be covered by your insurance. If your Insurance Company doesnâ€™t pay for the services, or or items provided, you will be responsible for payment in full. It is your responsibility to check on your in-network and out-of-network benefits which can vary widely amongst insurance plans. If you have not met your deductible, it may be collected at the time of service.
If we are out-of-network with you Insurance Company, you will be responsible to bring us all correspondence from the Insurance Company and sign over any insurance checks sent directly to you or make payment directly to AZTMJ.

Non-Insurance Patients

All payments are to be made at the time of service. We accept cash, check, and credit cards and also offer the option of financing your treatment. If you wish to bill an insurance company during any time during or after treatment for reimbursement we can provide you with the necessary forms upon request.

All Patients

A $ 75.00 fee is charged for missed appointments without a 24 hour advanced notice. A $ 35.00 fee will be charged for any checks returned for insufficient funds.
Any amounts that are 90 days past due may go to collections, and you agree to be responsible for legal fees (court, attorney, process server), collection agency fees, interest charges (2% per month) and any other expenses incurred in the collection of your debt.
If appliance therapy is utilized, we will require a $ 500.00 deposit towards the fabrication of the appliance(s).
If treatment is rendered on a minor child, the parent or guardian who accompanies the child to the appointment is financially responsible for the amount due.
I understand that all fees paid are for services rendered fees are not re- fundable and are not based on result of treatment.
By signing below, you understand and agree to the terms of this financial policy.

Patient Signature Acknowledgement*

FirstLast

Date*

Date Format: MM slash DD slash YYYY

Notice of Privacy Practices

To our patients: This notice describes how health information about you as a patient of this practice, may be used and disclosed, and how you can get access to your health information. This is required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Our commitment to your privacy

Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following important information.

Use and disclosure of your Health Information in Special Circumstances

The following circumstances may require us to use or disclose your health information:
1. To public health authorities and health oversight agencies that are authorized by law to collect information.
2. Lawsuits and similar proceedings in response to a court or administrative order.
3. If required to do so by law enforcement official.
4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat.
5. If you are a member of U.S. or foreign military forces (including veterans) and if required by appropriate authorities.
6. To federal officials for the intelligence and national security activities authorized by law.
7. To correctional institutions or law enforcement officials if you are an inmate or under the custody of law enforcement official.
8. For workers compensation and similar programs.

Your rights regarding your health information

1. Communication. You can request that our practice communicate with your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We wil l accommodate reasonable requests.
2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical and billing records, but not including psychotherapy notes. You must submit your request in writing to: AZTMJ Medical Records Dept. 9481 E. Ironwood Square Drive, Scottsdale, AZ 85258.
4. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to: AZTMJ, Attn: Office Manager, 9481 E. Ironwood Square Drive, Scottsdale, AZ 85258. You must provide u with a reason that supports your request for amendment.
5. Right to a copy of this notice. You are entitled to receive a copy of this notice of Privacy Practices. You may ask us to give you a copy of this notice at any time. To obtain a copy of this notice, contact any front office receptionist at AZTMJ, 9481 E. Ironwood Square Drive, Scottsdale, AZ 85258 or call (480)945-3629.
6. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice contact: AZTMJ, Attn: Office Manager, 9481 E. Ironwood Square Drive, Scottsdale, AZ 85258. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
7. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.
If you have any questions regarding this notice or our health information privacy policies, please contact: AZTMJ, Attn: Office Manager, 9481 E. Ironwood Square Drive, Scottsdale, AZ 85258 or call (480) 945-3629 for further information.
I hereby acknowledge that I have been presented with a copy of AZTMJ Notice of Privacy Practice.

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About us

With an accumulated experience of more than 30 years, the providers at HPI have a wealth of knowledge regarding head & face pain diagnosis and treatment. They all hold a Diplomate status from the American Board of Orofacial Pain (ABOP), indicating fulfillment of a rigorous written & oral exam process completed by only a few hundred doctors world wide.There are very few diplomate providers in the U.S. and Canada that practice orofacial pain full time.